Chapters Transcript Video Cardiac Issues and Sports Screening All right. So it is towards the end of July and starting towards August. So I thought this topic would be fairly timely. I saw actually someone today who needed clearance from a cardiology standpoint for sports after he passed out uh during the hot days of football practice. So I think this topic is fairly timely. Um just going through things step by step. As far as disclosures, I have done some consulting work for Echo Health, which is a digital stethoscope company over the last few years, I'm using images without copyright position. Uh permission, I should say permission, not position from uh a couple of different sources. And my pronouns are he and him? Because uh I have had some commercial um contact over the last few years. This particular talk when the slides were vetted by our ce committee to make sure that there was no potential conflict of interest. So I just wanted to make sure that was clear. As always, we usually start with some objectives. So three simple objectives. Um Most of which you probably know a lot of information about already. The first is we're gonna describe the normal parameters for heart rate and blood pressure in teen athletes. The second, which we're gonna identify physical exam findings that merit further investigation. And the third is we're gonna discuss issues regarding EKG screening of teen athletes. So, uh I like to start a lot of my lectures, especially for our residents with the bell curve. I'm sure you're all familiar with this curve in many different formats. The reason I do that is because um there'll be different levels of expertise for those of you who are listening to this talk. Some of you may know, 99% of this information already and have your own ideas and biases towards it and that's fine. Um Others may learn a lot. So either way, wherever you fall, uh hopefully the lecture will be of some use to you. You can even just take the dad jokes if that's all you need and you know, the rest of the information and topics. Well, I was interested when I took BLS recently, you know, they make you choose now before you answer the question, I know it. I'm sure. Or I really don't have any idea. I forget what the exact choices were. But I think anywhere you fall along that spectrum, hopefully you'll get something out of the next hour or so this uh slide reminds me that all this information which I'm speaking about is out there. You all have ready access to that. I don't particularly care uh whether it's Apple or Samsung or whatever phone that you like Google platforms, et cetera. But the point is is that all of the information is out there for you and your families uh to look up very readily. So this is more of a summary and discussion of the information that's out there and easy to find what I found out years ago is, is that rather than being, you know, the sole source of information over time, I'm sure you and I, I've turned more to tour guides almost. It's so I consider this to be a guided tour. Whenever I go to a museum, I always pay for the docent tour. I think it's much better. I think guided tours are much, much better from someone who has experience because they usually point out things that you wouldn't otherwise see on your own. Uh This particular picture is from, I believe the Salvador Dali Museum in Saint Petersburg. Although I don't recognize the paintings, so I'm not 100% sure. Always. When I do this talk, I've done it a few times before over the years. Uh One of the questions that comes up right away is, should we add ecgs as part of our sports screening protocols? And should we add limited echocardiograms as part of those sports screening protocols? We'll discuss that. Uh But first, I wanted to go through the current standard of care and what's out there and then we can discuss risk benefits cost analysis, et cetera for adding EKG S and echoes. And we will be talking about EKG S and echoes um EKG S in fairly in depth because that's something that you can do uh in your office or you can have done that you can interpret echoes. Obviously are gonna happen through our cardiology service or other cardiology services at the hospital. So we spend a little less time on echo. I like to do dad jokes. Uh Just to break up the monotony of me talking. And also so you have something useful to take away for this lecture. So we'll Sprinkle those throughout the talk. It also reminds me to make sure that there's no questions in the chat as we go along. So first dad joke, how does NASA organize a party? Anyone, anyone, anyone in the chat Marie, anyone in the chat? Get it right. I don't see anything yet. All right. Let me give this 1, 10 seconds to make sure our chats working. How does NASA organize a party? Anyone? Well, the correct answer is they plan it anyway, the 10 year olds love this stuff. I'm not sure if you all like dad jokes, but I like them and my patients tend to as well. Sima Taa, why is Auntie Sima from uh Indian matchmaker in my talk or late version of the talk for two reasons? Number one, because uh reminds me and shows you that I actually did update this talk fairly recently within the last few months. And number two, because one of her famous saying is, is that, uh you only get 60 to 70% of what you want. It's really hard to find 100% or get up to 100%. And I realize for this audience, we're all very high achieving people. We'd like sport, screening cardiology and life in general to be as close to 100% as what we'd like as possible. But the reality is it doesn't always work that way. So with that, uh let's go to what our current standard of care is. Basically, it's the same 14 point cardiology screening that's been going on for the last two years. So it's seven points in personal history, three elongated or detailed points of family history and then four things on the cardiac exam. So what we'll do is we'll just start with this because this is kind of the universal thing that we have right now recommended by the American College of Cardiology, recommended by the American Heart Association, endorsed by the American Academy of Pediatrics. So it really is the standard of what we do or different things. Um So things like personal history. So we'll go through these one by one, but things like chest pain, syncopy, exertion, unexplained dyspnea, fatigue, palpitations, prior recognition of heart murmur, elevated blood pressure, and we'll go through what that means in different cutoffs, which, you know, just as well as I do prior restriction from participation in sports for different reasons and prior testing of the heart family history of a couple different points, premature death, disability from heart disease at under age 50 a long list of different clinical conditions which will go through one by one. Finally, on personal exam, on physical exam. Do you have a heart murmur? How are your pulses, especially your femoral pulses to make sure you don't have coarctation. The different, I don't wanna say stigmata but physical features of Maran syndrome which will go through in greater detail for Maran solar stand and some of the connective tissue disorders and blood pressure, it says in the sitting position, although we can sometimes take it in different positions, especially with our autonomic dysfunction or pots patients. There's different versions of forms out there. I'm gonna actually just share one from my computer here. I thought this one was actually fairly nice. This is from the L A school district. I realize you all practice in different areas and different school districts. But I thought this one was fairly detailed. Uh my own kids school, they actually break it up. They have a questionnaire and then they have a form that you need to bring in to get your kids screened prior to participating in sports. But I think sports, excuse me. But I think this one pretty much has everything. Again. This is from the Los Angeles Unified School District it's available online and I just brought it up as an example. So you know, the questions just like the A HAAP and everyone recommends and you know, adds other things as well that I thought was actually fairly nice. Have you ever spent the night in the hospital? Have you ever had surgery? I like this section. Heart health questions about you. They added Kawasaki's disease, which is kind of nice, not standard for the older guidelines but still health questions about your family. There's obviously an orthopedic section as well. And then, you know, multiple different things for medical questions, but all pretty standard stuff, including things about hypertrophic cardiomyopathy, Marans, et cetera. Does your family have a heart problem or defibrillator? And I like this part about unexplained seizures and near drowning. All that for sudden cardiac death is useful as well. All right, let's go back to the slides for a few minutes. So going through the different seven things as far as history, personal history. If they mention chest pain, this is the why, what, when, where and how kind of section of the talk? If it's chest pain? The question is. Well, what kind of chest pain you and I probably see a lot of kids with different forms of chest pain. One key question is, is it exertional or nonexertional? Where exactly is the pain and exertional is kind of hard to tease out. There's a lot of kids that just aren't good runners and one of the metrics that most school districts use is running the mile. So if it's just that they don't run the mile well, but other than that, they're fine, they're fine playing other sports. They're fine in the pool, they're fine doing other sorts of activities or other sorts of sports that's less worrisome than they get exertional chest pain every time they exercise, just like adults, chest pain that radiates up towards the jaw or down, especially the left arm is more worrisome if it's a sharp pain that happens on both sides of the body, including both sides of the chest. So I always ask the kids, where is the pain? Sometimes they point to both sides all over up towards their shoulders, down towards their abdomen, et cetera. Then I'm less worried about it. It's, it's consistently over the heart or consistently over the left side. Then I'm a little bit more worried about it. What does it feel like? I try not to lead them too much into the questions, but them describe what it feels like. Is it a sharp pain? Is it a stabbing pain? Is it a pinching pain? Is it just that they can't catch their breath? More details always helps. How often do they get it? How long does it last? And I usually try to ask what makes it better and what makes it worse. So, you know, standard stuff that you would ask as well. I try to ask and maybe you can get some more information. Even during the screening portion of this. If they ever had a history of syncopy, the questions that make sense and questions that come to mind are, is it exertional syncopy or nonexertional syncopy? Meaning were they out there in a hot day? Like the patient I saw this morning who was doing a football practice on the day when it was in the nineties and wasn't drinking too much water or is it nonexertional that they're at home? And then they stand up and then they feel dizzy and then pass out. Obviously, those two scenarios are much different. What did it feel like? And what I'm trying to get for theirs is, do they have a prodromal symptoms? Either visual changes, any tactile simulations? Did their skin feel different? Do they feel like they were gonna throw up? Did voices sound far away? Did their hearing get muffled or did something else sound different to them? What did it feel like to them? How often are they getting any sort of dizziness or sinkable episodes? And how long do they last? Do they wake up right away and they feel fine or they not even pass out because they just feel like they're gonna pass out? What makes it better? So does it get better or worse when you stand up? Does it feel better when you sit down? Does it feel better when you drink et cetera, et cetera. How much are you eating and drinking? And we'll talk about that briefly in terms of people trying to cut weight, how that manifests in terms of great cardia hypertension, et cetera. But how much are you eating and drinking? And how much were you eating and drinking that day if you had a single episode? And are you trying to lose weight or gain weight? Which obviously many teen athletes do for their sports, for dyspnea, fatigue and palpitations. Again, similar things. When do you get your symptoms? Are they associated with exercise or not? What does it feel like in the teens terms? A lot of teens don't really like to talk to you or, or maybe they just don't like to talk to me. Um, but we do try to get them to open up and really describe their symptoms as best that they can. How often, how long is it happening? What makes it better? What makes it worse and how much does it interfere with your regular activities? Especially if it's fatigue? Right. You know, are they able to finish the sports that they want to do? Are they able to finish the mile or whatever they're required to do for pe class or is it interfering to the point where they may be failing the class or not getting a grade or not able to participate in certain levels of sports, varsity, et cetera rather than where they were last year? And that always helps, you know, how is it compared to where it was before, if you're trying out for a junior year, how do you do during your freshman and sophomore years? Were you able to do the same things or is this a big change for you? Most schools still run the mile, at least for the two years that they require, um, most athletes to be or not even athletes but students to be in physical examination classes or their pe classes. You know, what is your mile time? Fairly useful? Uh, because most kids know it or at least know a general range. Obviously, the kids that are running a mile in less than 10 minutes are in pretty good shape and in good shape for most athletics, 10 to 15 minutes means that you're running and probably walking a little bit. So you're socializing and walking, but you are able to complete it. So you're running some and walking some and greater than 15 minutes. Most people can do. Um, but they're walking for most of that mile prior. Heart murmur. That's pretty simple. Well, who heard the heart murmur and, you know, under what conditions do they hear? The heart murmur? What did they tell you about it was, you know, do they say it was an innocent heart murmur? They may not know those exact terms. But did they say anything that you needed follow up or you needed to see a heart doctor based on your heart murmur? And are you having any other associated symptoms? Meaning, you know, do they have strep throat at the time? Were they feeling fine at the time? Having the, uh, contact tends to help quite a bit as well? Elevated blood pressure? Well, how high was their blood pressure before? Have you ever seen a doctor for high blood pressure is probably a better way to phrase it. Um, we all, I'll talk about blood pressure here in just a minute and pull up some normal tables and then where was the blood pressure taken? Meaning with, is this a P uh A physical exam that's done as part of a group or is there somewhere where you can repeat their blood pressure? Is there somewhere where you can do a manual blood pressure? Because obviously manual is gonna be more accurate than just an automated blood pressure, especially if you're trying to do a repeat and really determine. Are they hypertensive or not? Um Five days of blood pressure reading at home is kind of falling out of favor, especially as ambulatory blood pressure monitoring is really coming out. Um Just uh we'll spend two minutes here. I'm gonna take a little offshoot on blood pressure. Used to be that during JCN, excuse me JNC seven for a long time, any time someone had high blood pressure echo was really on uh the short list of things to get done. So you would get an echo to see if they had increased wall thickness, et cetera, you know, better than I, but most of that has fallen out of favor. So even if the patient has elevated blood pressure, usually they see neurology first and get ambulatory blood pressure monitoring first when it comes to the point where they were considering medication, that's when they get the echo. And that's a significant change from where it's been before. I'm sure all of you are familiar with blood pressure tables. Let me just throw them up just so everyone sees them, um, different forms for that. Let's just pull that up here, obviously from almost any source online these days, whether it's on your phone, your computer, et cetera, ipad epic. Wherever you find them, there's blood pressure tables for both males, females, um, based on, you know, different ages, different sizes, et cetera, especially in terms of height and height, percentile in general. I know a lot of people are getting more and more, uh sensitive to blood pressure, particularly at cutoffs a little bit lower than before as we go through. You know, we'll talk about how high is too high in general. You want your blood pressure for your teen athletes certainly be to be below the adult cutoffs of 1 41st Sisto blood pressure and 90 for a diastolic blood pressure. But most people will consider even those too high again, depending on age and height. Um, but also you know, even when basically 1 20/80 the adult normals are good to keep in your head at 1 30 or I start getting interested, you know, especially 1 30/85 above 1 40 especially for a systolic blood pressure. I'm war interested above 1 60. You know, I'm really getting interested in thinking, is this a kid who needs more work up and above 1 80 I'd consider that extremely abnormal and wanted to know why their systolic blood pressure is so high in general, it tends to be the systolic blood pressure. That's more of an issue than the diastolic blood pressure. But you all see patients for sport screenings as well. I'm curious about your feedback of what you see and how you manage blood pressure issues. All right back. This slides a little bit as far as high restriction from sports. It's pretty simple. Why were they restricted from sports previously? So, what was the issue? Was it orthopedic? Was it cardiac et cetera? And as far as prior testing for the heart, this is pretty simple. Who did the prior testing? What did they do it for? When did you have the test? Where was it done? So hopefully we can get results. Um, and what were the results? All right, before I do my next dad joke, I should take a step back. Um There's lots of different ways to do sports screenings. Many of them happen at the schools. These days, many of them happen in your office or different settings. Sometimes it's in a group setting with stations. I'm sure I've done that personally and I'm sure you've done that in the past as well where one stations for blood pressure, one stations for heart rate, one stations for the heart, one stations for orthopedics, et cetera or all this could be done in your office. I think ideally most people would do it in their office in the context of some sort of physical exam where they worry about orthopedics and all kinds of other health issues, immunizations, et cetera. But practically, that's not how it happens, especially in July and August as the sport seasons are coming up. All right, we'll do one more dad joke and we'll check the chat just to make sure that there's no outstanding questions yet. Second dad joke is, what is the tree's favorite trick? I'll throw that out there to defer to you to the chat. So anybody, for, first of all, let's get the joke, right? What is a tree's favorite drink? Any guesses that he, there's a guess in here that says root beer. That is the correct answer. Root beer is a tree's favorite drink and not to belittle our topic of the day. Any questions Maria from the chat about, uh, especially about personal history of cardiac or other issues for the sports screening. So there's just a couple of comments about the news that just came out about lebron James son having a cardiac arrest during his, um, basketball practice yesterday. Um, I actually had not heard that yet. I must have not been up to date on ESPN et cetera. So I do not have any information about that. And then let me see. And then the other. Ok, so that's one of the comments and then somebody's asking what heart rate is too low. Uh, we're gonna get there, ok? And when we take a look at EKG S and we talk, we'll talk about heart blocks and when you get there. Ok, perfect. And then another person just asking at the end if you can comment on WPW findings versus syndrome and the recommendations for competitive sports participation. So just so I understand that question. So the what are the uh EKG findings of WPW will cover that in a little bit when we talk about EKG S and then sports restrictions for WPW. Yes, recommendations for competitive sport participation. Yeah. Uh we will cover that in a little bit more detail but as far as WPW to baseline, um it really shouldn't have any sports uh restrictions per se. It may need to be treated. But WPW kids can usually participate in all sports. And if Ronnie James who I believe was going to us c right, participating at UC had some sort of arrest, you're gonna probably see a lot more kids uh through your clinics. And so will I you know, because kids want to get screened after the Buffalo Bills player had an incident. I definitely saw a little spike, you know, as more kids wanted to get checked out to make sure that they didn't have anything bad happen just because it got so much publicity. But I'll have to take a look at that myself and see if we can find any further details. Thank you. I'm gonna, I'm gonna move on a little bit just so we can keep going and get through the material. Yes. What is the tree's favorite drink? Absolutely. It's gotta be root beer. All right, let's talk about family history. So what's difficult about the family history? It's a question also about who's completing these forms and when are they completing them? Right? They're pretty standard. You must have them in some sort of form. You know, we talk, we look at the Los Angeles unified Form and how they do things. Maybe you have one in your office, maybe you use something online, maybe as the patients or students and student athletes go through the different stations, they go through step by step to answer some of these questions. But if you ask most teenagers, any of these questions, they're not gonna have a whole lot of answers. Although surprisingly, if they had, you know, it's mom or dad or someone direct to them, uncle, its cousin, et cetera, they may have some of these things. So we'll just go through step by step. What they ask for is, is their premature death. So sudden aren't expected before age 50 is their disability from heart disease and a close relative, less than 50 years of age. If you just ask about family history, you'll also get information about grandma and grandpa, which is nice and valuable. But above age 50 a lot of people have heart disease. So we don't worry about that so much. And then we worry about particular things, hypertrophic or dilated cardiomyopathy. Long qt other channelopathy, morphines and other things. So all those things would be in consideration for anybody who has a sudden cardiac event. Um The most common thing that I hear is that it was some kind of heart disease and that they really don't have further details. It was just some sort of heart disease. So let's go through these and I'm just a little bit more detail. We actually, you know, as cardiologists usually have lectures on each one of these different things, but just to cover them pretty quickly, hypertrophic cardiomyopathy. Uh you don't look at a lot of echocardiograms, I imagine. But this echocardiogram towards the right side of the screen basically just shows in 123 and four that the wall thickness or how thick that this heart is is about twice as thick as normal. Uh It's the most common genetic heart disease. Some people quote up to one in every 500 people or one in every 500 families have it in the general population. In my experience, it's not quite that frequent, but about one in 1000 would be a reasonable estimate. Uh, and usually have thickened but not dilated. So it's thicker than normal and bigger than normal, but it's not stretched out and it usually presents in the left ventricle. So obviously, that's one of the things that we would be looking out for. And if there was a family history of hypertrophic cardiomyopathy or even cardiomyopathy in general, if they didn't know the type, then that's someone who should get screened because it's usually aal dominant. So a 50 50 shot that if mom or dad had it, then the child would have it as well. Yeah, skip one dilated cardiomyopathy is a little an opposite in the sense here. So this is an echocardiogram on the right hand side of the screen, this chamber here with the arrow, which may be small on your screen. But hopefully you can see this is the left atrium, this is the micro valve here and this is looking at the left ventricle here. The wall of the left ventricle is much thinner than it should be. So it's about as half as thick as it should be. Whereas the other one, the hypertrophic cardiomyopathy would have been out much thicker, would have been double the size. It was. So that's much more common. Uh both in adults and kids. So especially older folks, a lot of older folks end up having dilated cardio towards the end of their lives. So, a lot of times when we hear about heart failure, we hear about dilated cardiomyopathy rather than a hypertrophic or restrictive cardiomyopathy could present a whole lot of different ways, nausea, vomiting, chest pain, et cetera, et cetera. But it's one of the things that we do look out for it to make sure that the kids don't have Long Qt syndrome also runs in families. People think it's about one in every 3000 to 5000 people slash families. Obviously, if you say families and it's a little bit more frequent. Um Basically, there's abnormal repolarization, a prolonged QT interval, predisposes to a bad ventricular rhythm called to plant. Uh which is really, it's not always a perfusing rhythm with them. So sometimes, obviously, the patients don't do very well. It again is typically autosomal dominant, although there are some versions that are a recessive and there's many different genes identified. Again, we have a whole hour long talk about Long Qt syndrome, different types, different subtypes, et cetera. Um Great for test questions, et cetera, but probably not so great for this format. So one thing you know, there's again, you can talk about different kinds of long Qt syndrome. 12 and three. And there's, you know, up to seven different varieties these days, different triggers. So this is one of the things we ask is some died suddenly. What were the circumstances around that if they check off guests? You know, was it when they were having a sudden event? Was it when they were swimming? Was it a sudden, um, audio event? Was it during sleep, et cetera? And depending on the different types, once they're identified, there's different treatments uh including defibrillators or not one thing I did want to cover because, you know, if, if there was a family history or you're worried about long Qt syndrome is where you measure the QT interval, the standard usually comes from lead two. That's where the original standards came from. So that's where I measure the QT interval measured in lead two and you start at the beginning of the Q wave and measure it to the end of the T wave and then you have to correct it for their heart rate, which is the beets formula. All the, all the information is out there. What is normal. So up to 450 for a male would be considered normal as a teenager. 460 or even 470 in females would be considered within normal limits beyond that, for either uh would be considered abnormal. Beyond 500 is when people usually really start getting in trouble. Although there's some variants where even under um 500 they start getting in trouble and start passing out or having more symptoms treatment, we can go through that in more detail at a different time at a different lecture, but you can use beta blockers A I CD and mainly you want to avoid things that prolong QT, certain mens prolong their QT as well. Anesthesia becomes an issue and then there's different treatments depending on how bad it is. Mark syndrome. So fairly common, right? A lot of folks out there do have Marin Syndrome or other connective tissue disorders leads to certain cardiac things. The biggest thing would be aortic root dilation, hard to differentiate. Sometimes in very tall, thin athletic people, swimmers, basketball players, volleyball players, et cetera. What's normal based on their genetics, what's normal based on their family stature versus what's dangerous in terms of aortic root dilation or in terms of their microvalve aortic valve, et cetera. Um if they have eye symptoms, scoliosis, other things, then it's easier to figure out and then we worry about their pan tissue disorders. As far as the different characteristics of Marfan syndrome. There's a lot of great resources that can help you. Uh If you think your patient has that um, wrist sign scoliosis, peti, um all kinds of different things just to jump out for a second as well. The Marins organizations are excellent. Uh if you ever have a patient with it or if you know you yourself are interested or if you want to send patients to a certain way, the Marantz Foundation website Maran dot org, I think is fantastic I'm not connected with them in any particular way. But I think the information out there is fantastic. They go over things like key features and they go over step by step for different organ systems, what to look out for, for cardiovascular. They go through things step by step in terms of the order enlargement, et cetera, et cetera. And they even have a nice um not just fact sheets but also they discuss things about not just getting diagnosed but also management, including what to do in terms of physical activity, who can participate and to what degree I think that's under their management section. Yep. And signs physical activity guidelines. I thought their stuff is actually excellent as far as what they can do, they show someone golfing because the old traditional thing is that they can golf or hike and not do much else. Um But we could talk about different types of activities, et cetera. People have specific questions about their patience or uh things that they've experienced anyway, not to get into too much detail. Let's go back to our lecture through a slide about PTU excavatum because some of your patients when you go through their physical exam, even though it wasn't on the hap criteria, uh PTU can be significant. So especially if it's associated with the connective tissue disorder. The hall index is the gold standard on CT is best uh chest x-ray, you can make some measurements as well, but it. Uh CCT scan is the best way to do it. A higher index of two or less is considered normal. So it's the A P diameter versus the other diameter of the chest, the transverse diameter and you can look it up for yourself, et cetera. But hopefully that's of some use to you. Uh We have excellent folks through U CS F who are really good at fixing chest wall deformities. The three reasons to fix it. Obviously, if they're having pulmonary issues, if they can't get the air in or can't get the air out restrictive or obstructive lung disease. Uh Cardiac disease, which is pretty rare. I've only seen a few handful of patients who are really impacts how much blood flow is going in or out of their heart or the third reason being cosmetic A RVC, I'm gonna gloss through these pretty quickly because there's a lot of rare heart disease. A RVC is arhythmical, right cardiomyopathy. So someone has a family history of that that runs strongly in families and we worry about them doing sports. There's certain EKG findings which I won't bore you with anomalous origin of a coronary artery is one thing that we struggle with. Uh So the coronary are supposed to come off on the left side and the right side of the aortic valve. Sometimes it's not the usual arrangement and you can have a coronary artery that comes between the great vessels, the great vessels are usually pumping, you know, with higher pressure as the person's exercising. So, if you have an intra arterial course, the theory is, is that a coronary artery can get pinched off and cause downstream problems, uh, leading to collapse or worse. So, if someone has an alarmist coronary, it depends on what kind of coronary it is. Which coronary is the one that's anomalous. If it's the left coronary, that's a big problem because the left obviously supplies a very important left ventricle of your heart. Whereas the right, uh oftentimes the right is pinched a little bit or in an area where it's near the pulmonary artery, but doesn't always have reduced flow. So we don't always fix that one. Certified C PV T or catacomb cata Colin nerve, excuse me, Clomin sensitive polymorphic attack, cardia is another cause of sudden collapse. So if, if there's any family history of that, that also tends to run in families again, you may not get all this from your patients or their families, you may just get that there's some family sort of heart problem, but it is one out there that we worry about. And if someone collapses suddenly, something that would definitely look for either with genetic testing or other means, Brugada syndrome is also on there, Brugada, they tend to love in terms of, you know, recertification exams, et cetera, et cetera. The typical Brugada pattern is a cove T waves. These are in the right proportion lead so usually be 12 and three, you see a down sloping of the T wave as it comes back to its baseline. So that's particularly useful to look out for if people pass out if you see a kid post, er and then an EKG is one to go. Look, excuse me, a good one to look out for. I'm not gonna go into the rest in further detail. I'm sure I'm losing some of you already because these are fairly rare diagnoses. But if the patient mentions any of these is that they had a family member or an immediate family member with all these, that's someone that merits further investigation before you clear them for sports. All right, I'm gonna throw up another dad joke. So when do astronauts like to eat and while people are responding to that, Maria, we just covered a lot of info about different inherited conditions. Anything in the chat, any specific questions about those? There's a question asking is a history of stroke below 50 in family significant. Uh I'd want to know a little bit more about that, but I wouldn't necessarily uh prevent them from playing sports. So when I think of a stroke, you know, I think about any intra cardiac lesions. So especially at the atrial level, do they have a PFO et cetera? Uh And more importantly, do they have anything hypercoagulable state or other hematology concerns? But from a cardiac standpoint, I don't, I wouldn't restrict them based on a family history of stroke. Thank you. That's it for right now. I don't see any answers. Oh, here's a question. I don't see any answers coming in though. Um, how worried are we about sudden death and second degree relatives would like to address contradiction to a uterol for a child with asthma and an HCM and arrhythmia like WPW incident of recurrence of WPW after abla in any sports restrictions. Sorry, I was a bit long winded. Ok. So I think there's three things there. So let's go through them step by step. The first one was, um, I'm sorry, the first one was, how worried are we about sudden death and second degree relatives less, much less worried, obviously the first degree relative. So if it's a distant cousin or someone else, um, I'm not as worried what I want to know is, is what was it? So if they, if they can tell me particularly what it is, for example, if it's C PV T in a cousin or a second or if it's a second or third cousin, I'm not worried about it, that's too, are removed unless there's multiple family members. So for example, I have families with Long Qt syndrome where grandfather has it, then one of the parents has it and then two out of six kids have it and they have other cousins with it. So even though they're distant family members, there's someone immediate as well or if there's multiple family members that are distant, then I'm worried about it. But if it's a second or third degree removed or distant, then I'm not so worried about it. Um, when I asked, then have the parents had any symptoms? So for example, if someone had a distant family history of heper trophic cardiomyopathy, one uncle out of three had it. Does the dad have it, does the mom have it, have they had appropriate testing and then I would probably clear them but send them to cardiology. So I probably would get them tested, but I would let them play in between unless they're presenting with any symptoms if it's just a family history, but no symptoms and a distant relative, I would probably let them play and refer them to cardiology personally. Uh, but I would want to know a little bit more about what it was in terms of the second part was about WPW again, Maria. Is that right? Yeah. Once, um, contradiction to a buttery for child with asthma and an HCM and arrhythmia like WPW. So a Albuterol, you know, usually the standard treatment for a hypertrophic cardiomyopathy would be a beta blocker. So, if it was standard Albuterol, I'd worry about two things, I'd worry about the tachycardia and then I'd worry about, you know, if we've already beta blocking them, how is that gonna affect their asthma in general? Now, I still go by the ABC S, it's airway breathing in circulation. Their asthma is so bad that they need treatment. You want to treat the asthma first and we can either use sox or steroids or other means and use albuterol as needed. Chronically. It'd be nice if, you know, it just depend on how bad the hypertrophic cardiomyopathy was if they have any obstruction of blood flow leaving their heart that they're, they're gonna need a beta blocker. But, you know, we would consider calcium channel blockers or other things. So, can you use it? Yes, you have to be very judicious with it. Absolutely. Albuterol and WPW should be fine together. So that combination should be ok. Uh Again, depending on how bad their asthma is and what medicines we're using to treat the WPW, because one of the things that there's different, an AICs for WPW as well. Great. The last part of it is incidents of reoccurrence of WPW after abla and are there any sports restrictions? So new sports restrictions and generally when we quote people, uh for what I quote people for an EP study, which is an electrophysiology study and ablation is about a 5% recurrence risk. So there's about a 95% chance that one of our electrical specialists will go in, find the pathway, eliminate it completely and they won't have it ever again. There's a 5% chance that they either won't be able to find it. Um or as those fibers try to reconnect amongst themselves, the patient will have recurrent episodes. But once the ablation is done, I usually have them recover for about two weeks. So their cat sites in their legs and possibly their neck can heal up well and then they can go back to doing all sports. Great. Thanks. There are some guesses. There are some more questions, but to take a quick pause, there are some guesses. Their favorite time to eat is lunch time. That is correct. We have a smart audience today or at least one that likes dad jokes. So yeah, um, has not eat at lunchtime months ago. All right. Well, I'm gonna keep going, Marie, if that's ok and then we'll stop and do a couple more questions. Ok? Ok. Great physical exams. So hang in there. We're getting towards the good stuff, you know, as we go through our physical exam, what are we worried about as far as physical exam? Heart murmurs femoral pulses and, you know, I tell them I do this every day, you know, multiple times a day as far as feeling femoral pulses, I do do it on almost all of my patients. I tell them what I'm gonna do. So I usually start with the radio pulse and then say I'd like to feel the blood flow heading down towards your lower extremities. So I'm gonna feel along both sides of your legs. So we wanna make sure at some point that that is done to make sure that they don't have cohorts. We picked up cohorts in seven year olds, excuse me, seven year olds, 11 year olds, 14 year olds, obviously we pick it up a lot as babies as well. But it's certainly one that you want to think about. Especially if they're hypertensive, where they talk about different physical features of connective tissue disorders, Marin syndrome, et cetera and then blood pressure, uh, officially measured in the sitting position. And I think we've covered that fairly nicely in terms of tables, et cetera. All right. So let's move forward a little bit with EKG S. Again, the reason I wanted to cover EKG S in depth or at least in some depth uh during this lecture. And we have separate lectures from cardiology on how to read EKG S, how to do EKG S et cetera. But it's something that you may be asked to interpret in your office, even if they're seen at, you know, a group screening for physical exams that they come to your office. And one of the things that you can get is getting an EKG. So if we're looking at EKG S, we all know that EKG S change at different ages, right? So their heart rates much faster when they're a baby, much slower when they're a teenager. And then there's different normals for that you can pull from whatever source you like whatever your atop brain is, whether it's your phone, Harriet Lane online, Epic et cetera. There's all kinds of resources out there as far as what's normal. But I just wanted to show a few and then we'll talk about how slow is too slow and how fast is too fast. Um, since someone already asked that question and let's just answer it. Most of these folks coming through if we're talking about screening for a physical exam or screening physical exam for sports participation, most of them are gonna be teenagers, uh, or at least in the 10 to 18 range and most of them are gonna be fairly athletic. So how slow is too slow? Below 50 gets my attention. Uh, below 45 gets more of my attention. And below 40 I really wanted to know why. Um, the old trick of having them exercise for 60 seconds in the office or when whatever setting you're in tends to work really well. When you really worry about it, it's, when it just doesn't come up at all, the heart rate should at least double with 60 seconds of exercise. So, for example, if you're worried that the heart rate is slow because it's 48 when you're counting with your stethoscope or feeling the pulse and you have an exercise and it shoots up to 100 and 60 after 60 seconds of running in place doing pushups, whatever the athlete likes to do, most likely they're gonna be fine. Um, how fast is too fast? Anything above 200 sustained is too fast. So technically, it would be 2 20 minus the age, that old formula still works very well. So if you had a 15 year old athletic person, their heart rate could get up to 205 and in sinus tachycardia with, you know, running maximum exertion, et cetera, and that would still be ok. But if it's sustained about 200 beats per minute and not coming down, then that's a big problem. Just so, you know, the typical heart rate uh for presentation of SVT or Super Tao Cardia for a teenager when they present is faster than that, it's usually about 2 40. So it's somewhere in the 2 40 to 2 50 range, usually anywhere from 2 20 to 2 60 actually, although they can bring then faster or a little bit slower, but that's how fast is too fast. And then obviously the context is huge as well. If it's fast and they slow down and they hydrate and they feel good again and it's down to 1 20 after being 200 they're fine. If you know, they're just sitting there doing nothing and their heart rates consistently 1 60 going up to 1 80 they're not anxious, then that might be a problem as well. Just to contrast, this is a one day old. Um If you notice that this, I'm just gonna go through this real quick because the hour is getting late and I want to save some time for questions. I'm just gonna point out the leads that my, I usually jumps to lead one A BF and then B one V six. So in one and a BF, this kid, you know, has some wide access deviation and some right particular forces that are elevated because the kids only one day old uh V six, the T wave here is a little unusual. Uh and the R wave and S wave are a little unusual because they're so young. You just keep an eye on V 61 of the important leads as they get older, the heart rate is slowing down. The PR interval is getting a little bit longer and the T wave is now completely upright and doing well. Here in this five year old female, the heart rate is even slower, the pr interval is even longer. So it looks like a normal EKG for most people. And then by the time they're a teenager and this 15 year old male, um the heart rate is slower. The P Noval is a little bit longer up to 200 milliseconds between the start of the P wave and the onset of the QR S complex and the T wave is upright. Having a T wave that's upright is really important. And I'll show you a few examples of that. That's just one thing that you may want to take away from this lecture is a teaching point, this is also something that I find incredibly useful. So when we do the screening of sports screening, some people have proposed adding a screening EKG depending on how you interpret those EKG S. Most studies would show that anywhere between 1% and actually 1.8% is what they usually quote and 10% of those EKG S are abnormal. There's specific criteria that people have come up with called the Seattle criteria about what can be normal in the athlete versus what is normal in someone who's not so athletic, um please take a look offline or the slide that will be available to you as far as common things including for example, an incomplete right bundle branch block, which is completely normal for most athletes. Some ST segment changes including earlier polarization can be completely normal for the athlete and really not something that merits for the work up and something that they should be cleared for sports. There's different kinds of heart blocks. I get asked that fairly often. So I just wanted to throw this slide in there first degree heart block where the pr interval is longer than normal. But for after every P, there's a QR S and it's consistent, it's completely normal. Second degree heart block type one can also be fine, second degree heart block type two, we get more and more worried that's where you have P waves. Then all of a sudden drop. The QR S complex and type one, you get a prolonging of the PR and then you drop um a QS complex and third degree heart block where the atria ventricles aren't really talking to each other. It's always bad. Couple of um EKG S for my patients. Uh This one's already labeled nicely if you're looking here, this is an example of WPW. Just since there was a question of that, the EKG findings of WPW, you can see quite nicely in this kid's precordial leads. So V 12 and three or the right side, usually V four or five and six is the left side just taking a look here in V four. The Pr Noval, you know, it goes right up sloping into this triangular shape wave. I'm sure I'm not sure what kind of device you're looking at. It may be very small on your screen, but the classic findings are that there's the Pr Noval is off here, there's a wide Qs complex and then there's a delta wave so short, PR YQS and a delta wave, the classic UK G findings for WPWV three, you can see it very nicely here. WPW where it's certainly for the work up, but most kids with WPW can play all sports and do everything and we don't restrict them. At least I do oftentimes we get kids with premature beats, right. So premature ho contractions or premature ventricular contractions PV, CS five or even up to 10% PV. CS, single PV CS without Vetri couplets or without runs of ventricular ta cardiac can be normal for the young thin athletic person. Some studies will quote up to 20% of runners and other long distance kind of athletes, swimmers, water pole players and others. Having some PV CS isolated PV CS aren't necessarily a reason to restrict anyone from exercise or go on a beta blocker. This is just an example. I just like this one because this is my patient. Um This is the next slide because this is her sister. This is a normal EKG looking at V six where you have an upright U complex and an upright T wave. This is her sister who has hypertrophic cardiomyopathy. The cure complex is much taller. This left hypertrophy and leads P 45 and six and this T wave is abnormal. She has hypertrophic cardiomyopathy and her sister doesn't both by physical exam, genetic testing, et cetera, et cetera. So again, this is her older sister who does not have hypertrophic cardiomyopathy and this is my patient who does. So the EKG findings are vastly different. There are some special circumstances to consider as well. Um A lot of eating disorders out there, we won't get can spend a whole 60 minutes on that both with eating disorders. Again, when the heart rate is less than 45 we really start worrying when it's less than 40. That's probably a criteria for admission in consultation with your psychiatric team or other experts. And we're not just looking for the heart rate and someone with uh an eating disorder, we're looking at their QT interval, having prolonged QT interval is also an independent risk factor for badness. So that's the point where we usually admit a patient as well, very difficult conversations and obviously it's long term treatment that's needed. Um But something that we worry about quite often a DH D medication just because a long time ago there was a recommendation back in 2008 or so that all kids have an ECG before they start a DH D medicines. Uh, that's fallen out of favor, but most people can be on a DH D medicines and do just fine even with some underlying cardiac issues. All right, we're gonna throw up another dad joke and then take some time for questions at what point or so. Excuse me? At what time did most people go to the dentist? So, Maria, lot people more on that. Any other questions from the chat? Yes, we have a handful. Um, let's see here, addiction induce prolong qt interview interval. What is the most common drugs at pediatric group? Like Zithromax with Zofran or PROzac? All of those are on there. PROzac, I wouldn't throw on that list. Uh, a lot of the anti seizure medicines we worry about as well. So, but certain antibiotics, uh ng I medicines are the most common ones on the list. Zofran tends to be the biggest one these days. So a lot of, er, S will get a patient presents with severe nausea. They'll get an EKG and make sure that they don't have long QT before even giving Zofran. Great. Next question asking. Do you recommend a screening for ECG before starting a stimulant for a patient with a DH D? Yeah, standard. They don't need a screen EKD EKG. If there's a family history or if the patient is having any palpitations or other symptoms, then yes, if not, not every kid who's starting a DH D medicine needs to get an EKG. Thank you. That's question asking. Do teens on stimulants have higher risk to have cardiac events? Uh As far as I know, no, uh they can get tachycardia. But um, there's a whole, again, a whole other lecture on different side effects of the different stimulant medications and nonstimulant medications of what would be best. Um I have some patients who actually have underlying arrhythmia and still need to medicine. So basically I work with the psychiatrist or the pediatrician or practitioner just to figure out um what's the best combination for them. So you can use them even in kids who have underlying cardiac issues, you just have to be very careful and make sure that they're well managed. Thank you. Next question asking. Is there a minimum age for HOCM screening? Oh, good question. So not necessarily a minimum age. So if mom or dad have. It. Oftentimes, unfortunately, I see. Not, unfortunately, but I oftentimes see families that are affected by it or mom or dad passed away and then I'll start screening them even as an infant. It depends on the family history. Um, there's an interesting study out of Stanford. Oh, almost a decade ago where they recommended that most kids between age 10 and 18 because they're going through growth spurts get screened annually. But that's still controversial. Most cardiologists would screen them at least every three years. What's really nice these days is there's a lot of good genetic testing that screens for a lot different variants of hypertrophic cardiomyopathy. So if you, if that's the family history, usually what we do is do genetic testing and have a consult with the genetic service. Obviously, if the kid is genotype positive, the same one that either the parent or the whoever was affected the family had, then we're very careful. If their genotype and the patient or kid's genotype is negative and the parents is positive, then it's easy because we can let them play all sports and not screen as often forever. Great. Next question is two parts it's asking, it says might be a little off topic. But can you address screening for scuba or scuba clearance in general for teens? So the big thing that we worry about with scuba, which the patient, uh this person asked the question probably already knows is, are there any holes in the heart. So there's a chance that the patient may have what's known as a patent frame in a valley or a little flat valve between the top chambers of the heart between the atria. So I would recommend that they get screened for that before scuba. And then it also becomes an in a question of what, what depth, you know, are they coming up at a certain thing, et cetera, et cetera. I've had to say no to a few people for scuba because they've had either prior heart surgery or they have a small hole in their heart. So then the answer would be no at certain depths. So then they can, you know, snorkel and that kind of stuff, but anything at depth would be no. So I would recommend that if they really want to know then before scuba that they, they get a cardiac clearance. Thank you. Next parts asking does a single episode of syncope on a hot day require an EKG. Not usually if there's prodromal symptoms and you can explain it all, then I would let one go if there's anything funny about this story or there's any family history then getting an EKG makes sense. Thank you. Now, um Kudos to Peter Sam, he's been consistent in guessing your dad jokes and he thinks the answer is too, too 30. So 2 30 he's tried again. We have one or two more. So we'll see how everyone finishes up. But yes, at what time do you go to? Most people go to the dentist? The answer would have to be 2 30. All right. Uh I realize I'm running over time a little bit so I'll try to be quick finishing up here just to leave a couple of minutes for questions at the end as well. I won't spend much time on echo. There have been several proposals to add in echo. Um along with these sports screenings, uh the views that we usually get are a personal long access view for screening for an actual echo. We usually do about 60 different clips from all different angles of the heart looking at it above, from the side, from left, from the right, all different angles. So we see all four valves and chambers as well a quicker way to do that. Just if you're doing a quote unquote screening echo would be to do a para long axis view and then also do a four chamber view. You would pick up if the heart's way too thick. So hypertrophic cardiomyopathy, you would pick up if the heart's way too thin, you should be able to pick up a major bowel problem or if this aortic root is very dilated for something like a syndrome. The problem is without a full echo, you'll miss certain things. For example, the coronary arteries wouldn't be imaged well. And you could still have significant heart disease. Even if these two norm two views were normally you'd pick up more. But the question is, is it worth the expense and the trouble of the echocardiogram? Um One new slide I threw in for this particular talk is COVID questions, you know, obviously COVID is weighing significantly. So there aren't as many questions, but especially when it's at its height or one of its heights, uh special restrictions after COVID unless you actually had myocarditis And even most of those athletes, both collegiate level and high school level recovered nicely from myocarditis and were able to go back to playing after usually three months if not six months. And the same thing after a vaccine associated myocarditis after COVID vaccines. So just to finish up, um just to make sure we covered these as we're finishing up the talk, we were supposed to describe normal parameters for heart rate and blood pressure in teen athletes. I think we did that. We're supposed to identify some physical exam findings that merit further investigation. I think we did that and there's many different online resources for you to investigate yourself if you'd like. And we discussed some issues regarding EKG screening of the teen athlete. So with all that, I'd like to just talk a little bit about future directions and these are the questions that are fairly common that we've been asking for a decade. If not more. Should we do EKG S and everyone? And I'll go through an article here in just a minute for the last couple of minutes of the talk. Um, but there's new technology, you know, obviously you're watch, you know, the apple products or Samsung products or whatever watches you wear these days. Some of them do EKG S and some of them do them fairly well, not perfectly but fairly well. And then, you know, with a I where applications of artificial intelligence in terms of reading EKG S, one thing that's interesting when, you know, for the last 20 years, if not more many decades, when you get an EKG, there's a reading on it. So, although people think that A I is new, there's been computer programs that have interpreted EKG S for many decades and most of them actually do it fairly well, the more data they get and the more machine learning you apply, it'll get better and better echoes for everyone. It would be great if we can get an echo for everyone. But you're gonna pick up stuff, you know, don't forget about sensitivity and specificity. How many false positives you're gonna get about the heart wall thickness being a little thick and an athlete who's well, athletically trained, you get a lot better in the border line and remote olo patient support. So if you find a kid with am uh can you get someone to listen to that? So again, again, echo this stethoscope company and there's many other digital stethoscope companies um who will probably advertise that you can get support and send in a recording of the murmur to see whether it's pathologic or not. Um, I found personally that it's more like an IBM Watson kind of version. I watched IBM Watson play Jeopardy many, many years ago. What was interesting is they don't tell you yes or no. They just give you a percentage. So if you send in a recording of a heart murmur and you got an answer back that there was a 82% chance that it was an instant heart murmur. Is that good enough for you to clear that patient or is that someone that you would send to cardiology and you can make up whatever number you want? If it was 99.9% you'd probably be pretty sure. But if it was 64% would you be sure enough or not? Um tons of logistics and payment options and you know, from a public health angle, equity inclusion, you know, predominates as well, how we're gonna make sure that everyone has equal access. And so only some kids, you know, would it be fair if only some kids got EKG S and echoes at an additional level at certain schools or areas? And what about the other kids who couldn't get access to those kind of resources? Almost with anything else? I like Venn diagrams and I like the overlap. Uh you know, sensitivity and specificity probably better than I do. But any time we want to add more questions to the screening or add any ecgs or Echoes, there's always concerns about false positives, false negatives and sensitivity and specificity for an excellent recap of all that because I'm running out of time. I do want to cover some of this. So just so we have that here, this um either Maria or someone else, maybe you could put it as a link to uh this talk as well, but this will be part of the slides as well. I found this article to be excellent. It came out a couple of years ago and it covers pre participation, cardiovascular screening and young competitive athletes by these authors. And what I liked about it, it went through kind of what we have that 14 question things that we talked about that standard with the different organizations. But it also went through nicely about cost analysis and how much you would um miss and how much more you would see in terms of sensitivity and specificity for just H and P alone versus adding in an EKG versus adding in an EKG and echo and how that may uh relate terms to cost. Interestingly without a true, you know, common universal health care system costs are much higher because they've looked at studies not just here in the US, but they also looked at studies in Italy uh in Europe and other places. And obviously the costs there were low they looked at using the Seattle criteria versus not so trying to reduce the, the false positive EKG S with the Seattle criteria, but it was still up to 6% were false positives even by applying the Seattle criteria better than 10% but still not optimal. And then the rates vary widely in the different studies, somewhere between 1.3 and 6.8. So, um again, I can go through this in more detail, but I think the hour is running late. So I'll let you take a look at that as well. Again, great article about does adding EKG and echo. How much more do you find? Is it worth it? And what is your number needed to treat versus what is your number in terms of cost and benefit? So again, I highly recommend this article. It'll be available to you later in the chat and then let me jump to our last dad joke of the day. So I'll let you ponder why can't dogs get MRI S as our last dad joke of the day with that Maria? Any other questions from the chat? Yeah, there's a couple in here. If an A DH D patient wants to play sports and has elevated blood pressure, what do you suggest? So, first of all, I wanna know how high that blood pressure is and is that under what kind of settings? Uh and then if they want to play some of the medicines that are used for a DH D quantity comes to mind. Uh Other ones can be used in conjunction to bring down blood pressure and do that as well. So, you know, theoretically there should be able to get a medication mix where the patient is stable and can still play sports. But it depends on what the blood pressure is. Right? If the blood pressure is consistently above it, so of 1 60 then I'm much more worried about it. If it's borderline, meaning if it's 1 35 or 1 42 then I'm a little less worried. Thank you. Is EKG recommended for athletes who ever have had COVID prior to playing, even if no HX of myocarditis does timing matter. So currently not standard. So most people, uh this is not a COVID talk, I'm not a COVID expert and there's lots of different information out there. But as far as I know, there's not a recommendation for standard screening with an EKG if someone's had COVID, however, if it's recent and they're still having symptoms, I think getting an EK is reasonable, for example. So I saw a patient today who had COVID earlier this month, uh was diagnosed with COVID on the fifth of July. So if that patient told me that they were having chest pain or any sort of fatigue before I cleared them for sports, getting an EKG would be reasonable. But if they had it two years ago, I don't think they need to get an EKG great last questions asking in European countries with universal health care. Are they screening with EKG S for all sports, physicals, et cetera depends on the country. Uh So the Italians, uh for example, years ago and I haven't reviewed the Italian literature lately. At the high school level, they would get EKG S and at the professional or collegiate level for their, I just think Italians and soccer, but for all levels of sports, uh they were actually getting echocardiograms but screening echocardiograms with limited views and with that, there's numbers out there as far as what they found, how many patients they needed to see in order to find something, et cetera, you will need to screen a lot of patients before you find something. And the question is for that one in 4000, 1, in 6001 in 12,000, et cetera. Um Is it worth it depending on the cost of everything else? So there's some, if you're, if that person's really interested, just look up Italian Italian cardiac screening for athletes and you'll find a lot of information. There's, I believe some stuff from Switzerland and, or Sweden as well, I don't remember, but the Italians tend to be the ones that do it the most. Thank you. So, Peter Sam is saying for your dad joke, they prefer pet scans. Uh That is a good take on this. But why can't dogs get an MRI well, because only cats can't. Oh, very good. Yeah. S angle, the pet scan angle is actually pretty good. Yeah, I thought he had it. Yeah. So that's the end of my talk. I tried to stay on time. I realized that this was a lot of information and some of it was applicable to a lot of you and then there's other specific questions you have about your patients. Thank you for your attention. Um, Maria, is there anything else we need to close up as far as housekeeping? That's it. All the attendees will be getting a copy of your slides and we'll share your, um, email too. You have it here on this slide deck. If there's any other questions for doctor bows, we really appreciate doctor bows. You taking the time to present to us today and all the work you put into it and thank you everybody for attending. Have a great day. Good luck to everyone. Take care. Created by
